“appropriate health services” means health services in relation to the diagnosis or treatment of the illness or injury of a patient which would be accepted generally by the medical profession as appropriate and necessary, having regard to good standards of medical practice and to the nature and cost of any alternative forms of treatment as well as to all of the circumstances relevant to the patient;

“cell” or “specified cell” means a group of insured persons who belong to both a common gender and a common prescribed age band;

“cell prescribed benefits” means the sum of all prescribed benefits paid, in respect of settled claims which acquired that status during the quarter concerned, to or on behalf of covered persons but disregarding any prescribed benefits paid which have been taken into account under a previous settled claim;

“cell claim value” means the sum of all in-patient and day-patient days, in respect of settled claims which acquired that status during the quarter concerned, in respect of covered persons but disregarding any such hospital stays which have been taken into account under a previous settled claim;

“claim” means an application by, or on behalf of, an insured person to a registered undertaking for the discharge or reimbursement, under the terms of a health insurance contract, of all or part of the fees or charges due to a health services provider in respect of the provision of prescribed health services during a hospital stay or stays;

“covered persons”, in relation to a registered undertaking, means—

(a) insured persons who on the last day of a specified period were named in a health insurance contract effected by that registered undertaking and who belonged on that day to a specified cell or combinations of cells,

(b) persons not already included under subparagraph (a) who, during the same specified period as in that subparagraph, were named in a health insurance contract effected by the registered undertaking and who, but for the cessation of their health insurance contract, would have belonged to a specified cell or combination of cells on the last day of that specified period, or

(c) persons not already included under subparagraph (a) or (b) and—

(i) in respect of whom there was a settled claim during the same specified period as in subparagraph (a), and

(ii) who were formally named in a health insurance contract effected by the registered undertaking and who, but for the cessation of their health insurance contract, would have belonged to a specified cell or combination of cells on the last day of that specified period;

“corrective payment” means a payment made to, or an amount recovered from, a health service provider or an insured person in respect of prescribed health services for which an incorrect payment, other than one arising from a systematic error in the method of processing claims, was made;

“day-patient day” means a day, including a day upon which an in-patient stay commences and ceases, during the course of which an insured person is maintained in private hospital accommodation for the purpose of receiving day-patient services;

“fixed price procedure” means any prescribed health service, the benefit for which is payable by an undertaking to a publicly funded hospital or a private hospital, on behalf of an insured person by reference to a specified monetary amount agreed between the undertaking and the hospital as representing full settlement of all charges and fees arising;

“gross provider payment”, in relation to a settled claim, means a payment or payments, based on proper and correct accounts, due, or nominally due, from a registered undertaking to a health services provider or in respect of services rendered by that provider, disregarding the effect of—

(a) any third party recoveries in respect of that claim,

(b) any corrective payments in respect of that claim,

(c) any discounts, overall limits or like reductions or bonuses or other additional compensation which may have been agreed between that provider and that undertaking, and

“hospital consultant” means a registered medical or dental practitioner who by reason of his or her training, skill and experience in a designated speciality, is consulted by other registered medical practitioners and who has a continuing clinical and professional responsibility for patients under his or her care, or that aspect of care on which he or she has been consulted;

“hospital stay” means an in-patient stay or a day-patient day or any attendance at a hospital during the provision of services described in item 1 of the table to Article 1 of Schedule 1 while the insured person was maintained in accommodation other than private hospital accommodation;

“in-patient day” means a day during an in-patient stay where the day on which the stay ceased is deemed a whole day and the day on which that stay commenced is disregarded, except that if that stay commenced and ceased on the same day then that day shall be deemed a day-patient day;

“in-patient stay” means a continuous period during which an insured person is maintained in private hospital accommodation for the purpose of receiving hospital in-patient services, such period—

(a) to commence on occurrence of the later of—

(i) the most recent admission or transfer of that person to private hospital accommodation, or

(ii) the cessation of the most recent previous hospital in-patient stay in respect of that person,

and

(b) to cease on the occurrence of the earlier of—

(i) the next subsequent discharge or transfer of that person from private hospital accommodation,

(ii) the death of that person, or

(iii) the date designated as the cessation date of that period by the registered undertaking which effected the health insurance contract under which that person is named;

(a) a person named in a health insurance contract as an insured person, and

(b) from date of birth, any infant born to any person named in a health insurance contract, provided that the person who effected the said contract requests that it be altered to name any such infant as an insured person, and pays the appropriate premium, if any, in that respect, within 13 weeks of the infant’s date of birth,

but does not include—

(i) any person named in a health insurance contract which does not relate to inpatient indemnity services,

(ii) any person named in a health insurance contract which relates solely to public hospital daily in-patient charges under Regulations made pursuant to
section 53
of the
Health Act 1970
(No. 1 of 1970), or

(iii) any person who has not completed an initial waiting period;

“medical condition” means any disease, illness or injury;

“net provider payment” has the meaning assigned to it by Regulation 4(2);

but excluding a nursing home, or a hospital which is outside the State;

“private hospital accommodation” means accommodation in a private hospital or accommodation in a publicly-funded hospital in a bed which is designated, pursuant to Article (8)(i) of the Health Services (In-Patient) Regulations 1991 (
S.I. No. 135 of 1991
), as a designated private bed;

“private psychiatric hospital” means a centre, within the meaning of
section 62
of the
Mental Health Act 2001
(No. 25 of 2001), registered pursuant to section 64 of that Act;

“publicly-funded hospital” means a hospital, other than a private hospital or nursing home, which provides services to a person pursuant to his or her entitlement under Chapter II of Part IV of the
Health Act 1970
(No. 1 of 1970);

“quarter” has the meaning assigned to it by section 2(1) of the Act of 1994;

“relevant period” has the meaning assigned to it by section 7D(1)(b) of the Act of 1994;

“returning undertakings” means all registered undertakings or former registered undertakings required to make the information return concerned by virtue of section 7D(4) of the Act of 1994;

“screening” means a medical examination or test that is not reasonably required for the diagnosis of, or management of, the medical condition of an insured person;

“settled claim” means a claim in respect of which payments due have been made but excluding any claim in respect of a person who, at the time of the hospital stay or stays to which the claim relates, had not completed an initial waiting period;

“third party recovery” means a payment made to a registered undertaking as a result of payments made by a third party for fees or charges arising from the provision of prescribed health services to an insured person other than payments made in respect of a contract of reinsurance.

(2) The definitions of “quarter” and “relevant period” in paragraph (1) shall not be construed to prejudice the generality of the application of
section 19
of the
Interpretation Act 2005
(No. 23 of 2005) to the construction of these Regulations.

3. The Authority shall have all powers that are necessary for or incidental to the performance of its functions in relation to these Regulations.

PART 2 DETERMINATION OF PRESCRIBED BENEFITS

4. (1) A returning undertaking shall calculate and record, in respect of each settled claim, the amount of prescribed benefits in accordance with the provisions of this Regulation and Schedules 1 and 2.

(2) In respect of each settled claim and for each health services provider, the returning undertaking shall determine an amount (to be known for the purposes of these Regulations as the “net provider payment”), being the gross provider payment in respect of that claim and that provider multiplied by an amount determined in accordance with the formula:

A

B

where, for the quarter in which that claim was settled—

A is the sum of:

(a) the total of actual amounts which that undertaking has paid, disregarding the effect of any corrective payments and third party recoveries, in respect of all settled claims which acquired that status during that quarter; and

(b) the net total of corrective payments relating to that undertaking during that quarter, provided that this amount shall be subject to an upper limit of 0.5% of B and be subject to a lower limit of –0.5% of B, reduced by the total of any third party recoveries made by that undertaking during that quarter; and

Bis the sum of that undertaking’s gross provider payments under all settled claims which acquired that status during that quarter.

(3) The prescribed benefits in respect of each settled claim shall be the sum of the net provider payments under that claim, where each such net provider payment is subject to the maximum limits specified in Schedule 1 as regards the type of payments contained therein.

PART 3 SPECIFICATION AND MAKING OF INFORMATION RETURNS

5. (1) Each returning undertaking shall make information returns to the Authority in accordance with section 7D of the Act of 1994.

(2) Form No. 1 set out in Schedule 2 shall be the prescribed form of information return to be completed by each returning undertaking and submitted to the Authority.

(3) A returning undertaking shall ensure that each of its information returns contains:

(a) for each quarter within the relevant period to which the return relates, the details specified herein in respect of each cell by gender and related aggregate details:

(i) the number of insured persons on the first day of each month of the quarter;

(ii) the cell prescribed benefits for the quarter;

(iii) the cell claim value for the quarter;

(iv) the aggregate details in respect of subparagraphs (a), (b) and (c) for the gender concerned;

(v) the aggregate details corresponding to subparagraphs (a), (b) and (c) for all cells for both genders combined; and

(b) where the quarter is the second quarter of the relevant period, the number of insured persons on the first day of the first month of the first quarter of the immediately succeeding relevant period.

(4) A returning undertaking shall ensure that each of its information returns is accompanied by an analysis, for each quarter within the relevant period to which the return relates, of the difference between—

(a) the following:

(i) the total number of persons (including such persons excluded from the definition of “insured person” by virtue of subparagraph (i), (ii) or (iii) of that definition) named in health insurance contracts effected by that registered undertaking that are in force on the first day of the quarter; and

(ii) the total number of insured persons on the first day of the quarter for all cells for both genders combined,

and

(b) the following:

(i) the total amount of payments made under health insurance contracts during the quarter; and

(ii) the total amount of the cell prescribed benefits for the quarter for all cells for both genders combined.

(5) A returning undertaking shall ensure that each of its information returns is accompanied by a statement setting out the details of the material assumptions (if any) used in preparing the return.

(6) A returning undertaking shall ensure that each of its information returns is accompanied by a report by an independent accountant stating whether or not, in the opinion of the independent accountant—

(a) the return has been prepared in accordance with these Regulations in all material respects,

(b) the material assumptions (if any) used in preparing the return are appropriate, consistently applied and adequately disclosed in the statement referred to in paragraph (5), and

(c) the return has been prepared in accordance with the underlying books and records of the undertaking.

(7) The independent accountant referred to in paragraph (6) shall set out in the report referred to in that paragraph the basis for his or her opinion referred to in that paragraph and include in the report such findings or qualifications as he or she considers ought to be included in the report in the circumstances of the case.

(8) A returning undertaking shall ensure that—

(a) each of its information returns is confirmed by being signed by 2 of its officers who are authorised to do so by the Board of that undertaking, and

(b) one of those signatories is the managing director, the chief executive officer, or the company secretary, of the undertaking, or a member of the Board of the undertaking, or a person of similar status in relation to the undertaking.

(9) If a returning undertaking detects or otherwise becomes aware of an error in an information return which it has made, it shall forthwith notify the Authority of such error and, within 7 days of becoming so aware, submit a corrected information return (to be known for the purposes of these Regulations as a “data adjustment”), together with a report setting out the reasons why the error occurred and the steps which have been taken to prevent a recurrence of any such error.

(10) If the Authority receives a data adjustment, it shall, if time permits, incorporate the data adjustment into its evaluation and analysis required under section 7E of the Act of 1994 to be carried out for the relevant period concerned. If a data adjustment is received when it is not possible to incorporate it into such evaluation and analysis or report required under section 7E of the Act of 1994 to be furnished to the Minister, and the Authority considers it to be a material data adjustment, the Authority shall advise the Minister of the impact that the data adjustment would have had on its evaluation and analysis and report as soon as is practicable after the receipt of the data adjustment. The Minister shall have regard to any such advice in making recommendations to the Minister for Finance pursuant to section 7E(2) of the Act of 1994.

PART 4 SPECIFICATION OF PENAL REGULATIONS

6. Paragraphs (1), (3), (4), (5), (6), (8) and (9) of Regulation 5 are hereby declared to each be a penal Regulation for the purposes of subsection (1)(b) of section 4 of the Act of 1994.

SCHEDULE 1MAXIMUM LIMITS OF NET PROVIDER PAYMENTS

1. The maximum limit of net provider payments for prescribed health services provided by a publicly-funded hospital or a private hospital to an insured person, which are not fixed price procedures, are as set out in the following table:

TABLE

Payments in respect of:(Column 1)

Maximum Limit:(Column 2)

Item 1Prescribed health services which are hospital in-patient services provided by a publicly-funded hospital while the insured person was maintained in accommodation other than private hospital accommodation.

Limit for Item 1The public hospital daily in-patient charges under Regulations made pursuant to
section 53
of the
Health Act 1970
, and any other charges that may be payable under that Act as in force from time to time.

Item 2Prescribed health services which are hospital in-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

Limit for Item 2The amount of the charge payable under
section 55
of the
Health Act 1970
plus the amount of the public hospital daily in-patient charges under Regulations made pursuant to section 53 of that Act.

Item 3Prescribed health services which are hospital in-patient services provided by a private hospital other than a private psychiatric hospital.

Limit for Item 3The lesser of:€550 for each in-patient day;or100% of the charge made by the private hospital less €100 for each day during which the insured person was accommodated in a single room.

Item 4Prescribed health services which are day-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

Limit for Item 4The amount of the charge payable under
section 55
of the
Health Act 1970
plus the amount of the public hospital daily in-patient charges under Regulations made pursuant to section 53 of that Act.

Item 5Prescribed health services which are day-patient services provided by a private hospital other than a private psychiatric hospital.

Limit for Item 5The lesser of:€550 for each day-patient day;or100% of the charge made by the private hospital.

2. The amount determined under this Schedule in respect of hospital charges relating to childbirth by means of a normal delivery shall not exceed €1,000.

3. In respect of fixed price procedures, the maximum limit of net provider payments shall be the lesser of, the amount paid or 90% of that specified in an agreement between the undertaking and the hospital as representing full settlement of all fees and charges payable for the particular services concerned.

4. The maximum limit of net provider payments in respect of prescribed health services provided by a hospital consultant shall be the amount paid by the undertaking for the particular services concerned.

5. In respect of prescribed health services provided outside of the State, the maximum limit of net provider payments shall be the lesser of, the maximum limit of net provider payments in accordance with the other provisions of this Schedule, or the amount paid by the undertaking for the particular services concerned in accordance with a health insurance contract.

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to Age 79

Age 80 and over

All cells for that gender combined

Form No. 1

PART 1 OF RETURN (Continued)

Data for First Quarter of Period:

Gender: Male

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to Age 79

Age 80 and over

All cells for that gender combined

All cells for both genders combined

Form No. 1

PART 2 OF RETURN

Data for Second Quarter of Period:

Gender: Female

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Number of insured persons on first day of the next following period

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to Age 79

Age 80 and over

All cells for that gender combined

Form No. 1

PART 2 OF RETURN (Continued)

Data for Second Quarter of Period:

Gender: Male

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Number of insured persons on first day of the next following period

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to Age 79

Age 80 and over

All cells for that gender combined

All cells for both genders combined

Form No. 1

Return for the Period Ending .................................. as confirmed by:

Name: ....................................................Name:

*Position: ..............................................Position:

Signature: ..............................................Signature:

Date: ......................................................Date:

*One of the signatories must be the managing director, the chief executive officer, or the company secretary, of the returning undertaking, or a member of the Board of the returning undertaking, or a person of similar status in relation to the returning undertaking.

GIVEN under my Official Seal,

29 July 2009.

MARY HARNEY,

Minister for Health and Children.

EXPLANATORY NOTE

(This note is not part of the Instrument and does not purport to be a legal interpretation.)

This statutory instrument sets out the format and content of the information returns specified in Section 7D of the Health Insurance Acts. The purpose of the information returns is to enable the Authority to report to the Minister as set out in Section 7E of the Acts and in particular to recommend any changes in the levy and tax credits having considered the need to support the principal objective as specified in the Acts.